Car Quotation Form

Have you or any of the drivers ever had insurance declined or cancelled?

Title

First Name

Surname

Date of Birth

House Number & First Line of the Address

Postcode

Phone Number

Employment Status

Type of License

How long have you held this licence?

If less than 3 years, licence obtained date?

Were you born in the UK?

Registration Number

Value

Purchase Date

Are you the registered keeper?

Are you the registered owner?

Use of Vehicle

Any no Claims Discount (NCB)?

What is the maximum voluntary excess?

Start Date

Do you have any Accident? If YES, please mention below information-

Accident Date: Fault or Non-Fault: Damaged Amount (if known):

Do you have any Conviction? If YES, please mention below information-

Conviction Date: Conviction Code: Points: Fine: Ban:

Any Additional Driver? if YES, (First Name: Surname: DoB: Relationship: License type: License date: UK residency: Any Accident or Conviction:)

Comments:

I agree to the Terms & Condition and Privacy Policy.

COMPARE INSUREX IS AN ONLINE BASED COMPANY AND DOES NOT ENGAGE IN ANY REGULATORY ACTIVITIES. HOWEVER, WE ARE REGISTERED WITH THE INFORMATION COMMMISSIONER’S OFFICE AS WELL AS GDPR COMPLIANT, AUTHORISED TO PROCESS PERSONAL DATA UNDER THE DATA PROTECTION ACT & GDPR 2018. REGISTERED IN ENGLAND & WALES, COMPANY NUMBER: 15346638

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